Personnel Record
(Form to be completed by employee)
Date
-
Month
-
Day
Year
Date
Name of Facility
Facility Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Facility File Number:
1. Personal
Name
*
Last Name
Middle Name
First Name
Phone Number
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you 18 years of age or older?
Please Select
Yes
No
If under 18, please state your age
Social Security Number
(VOLUNTARY FOR ID ONLY)
Date of last physical examination
-
Month
-
Day
Year
Date
Date of last TB test
-
Month
-
Day
Year
Date
Have you ever been employed under a different name?
Please Select
Yes
No
If yes, please list all names used:
Please do not exceed 200 words.
Do you possess a valid California drivers license?
Please Select
Yes
No
List CDL # (if applicable)
Has your drivers license ever been suspended or revoked?
Please Select
Yes
No
If yes, please explain:
Please do not exceed 200 words.
Nearest Living Relative Name:
Name
Phone Number
Please enter a valid phone number.
Relationship:
i.e mother, father, brother, aunt
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Position
Title
Salary
Hours
Date of Employment
-
Month
-
Day
Year
Date
Name of Supervisor
3. Previous Employment
(List most recent experience first)
Please Include Employer: Name, Address, Phone Number, Job Title & Type of Work, Reason for Leaving and the Dates that you worked there. Separate each employer with a space.
4. Education
Select Highest Year Completed
6
7
8
9
10
11
12
High School Diploma
Yes
No
Currently Enrolled in High School Completion Course?
Yes
No
If yes, give expected completion date:
-
Month
-
Day
Year
Date
Employment Related Education Courses
Please list: Course Title, Name of School or Organization with Address, Number of Units Completed, Date of Completion or Currently Enrolled
Please list: Name of University, College or Business School with Address, Major Subject, Number of Years Completed, Number of Units Completed, Diploma Degree or Certificate & Date of Completion
5. References
List names of three persons who can give information about your background, character, abilities, etc.
Please list: Name, Address, Phone Number & Relationship to You
5. Professional & Technical Qualifications
A. List Licenses or Certificates of Competence held:
B. Names of Professional Associations of which you are a member:
List any additional notes you would like to add:
I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification:
Date
-
Month
-
Day
Year
Today's Date
Submit
Submit
Should be Empty: